L'Allergia alle proteine dell'uovo, la
biologia molecolare e la dieta



Calvani Mauro
Azienda Ospedaliera S. Camillo-Forlanini
U.O.C. per il Governo Clinico in Pediatria

ed Ematologia Pediatrica

Roma
Azzurra
Novembre 2011
Allattata al seno esclusivamente fino a 5 mesi e mezzo poi svezzamento. Alla
introduzione di formaggino plasmon, alla terza somministrazone ha subito
manifestato una eruzione cutanea del viso con angioedema dell'occhio, starnuti ,
rinorrea e difficoltà respiratoria per cui accesso in PS trattata con bentelan e
tinset. Sintomi regrediti dopo alcune ore. Dopo 10 giorni la pediatra ha tentato
una nuova somministrazione del formaggino mellin con analoga sintomatologia,
ma più leggera per rifiuto dal secondo cucchiaino, trattata con bentelan 1 mg .
Quindi posta a dieta senza proteine del latte con latte di soia e poichè sospettava
allergia ai conservanti del formaggino dopo circa 1 mese ha somministrato del
prosciutto cotto con analoga reazione generalizzata alla 3a introduzione, per cui
dieta rigorosa senza latte.
A 13 mesi introdotto l'uovo sotto forma di tuorlo cotto, che ha tollerato, ma alla
introduzione dell'albume cotto, ha manifestato analoga sintomatologia cutanea e
respiratoria, con accesso al PS per cui dieta senza albume ma con tuorlo cotto,
senza problemi fino ad ora. Circa 1 mese fa ha introdotto del parmigiano
stagionato senza evidenti reazioni, ma nuova reazione generalizzata dopo aver
mangiato del formaggio di pecora.
Azzurra
Novembre 2011
SPT
Lattalbumina = 8 mm
Caseina = 4 mm
Beta lattoglobulina = 6 mm
Albume di uovo= 7 mm
Tuorlo di uovo = 5 mm
Istamina = 6 mm
Controllo = 0 mm
Si consiglia dieta priva di proteine del latte
vaccino e latti animali e priva di uovo.
Consentite eventualmente solo le piccole quantità di
latte o uovo cotto che fino ad ora ha tollerato
Azzurra
Maggio 2012
Nel periodo trascorso è stata bene, sempre a dieta senza
latte con latte risolac e alcuni biscotti del mulino bianco
che contengono tracce di latte e di uovo, senza evidenti
reazioni, ha mangiato della cioccolata al latte senza
problemi, assume circa ½ del tuorlo dell'uovo cotto, e
alcune volte della pasta all'uovo, senza evidenti reazioni
Azzurra
Maggio 2012
SPT (Novembre 2011)
SPT (Maggio 2012)
Lattalbumina = 8 mm
Caseina = 4 mm
Beta lattoglobulina = 6 mm
Albume di uovo= 7 mm
Tuorlo di uovo = 5 mm
Istamina = 6 mm
Controllo = 0 mm
Lattalbumina = 4 mm
Caseina = 5 mm
Beta lattoglobulina = 3 mm
Albume di uovo= 6 mm
Tuorlo di uovo = 4 mm
Ovoalbumina = 6 mm
Ovomucoide = 1 mm
Istamina = 6 mm
Controllo = 0 mm
Si consiglia di continuare la dieta in atto, ovvero con uovo cotto,
come fino ad ora consumato, ma senza uovo crudo o in altre
forme e dieta senza latte, ma con gli alimenti contenenti tracce
Ulteriore controllo per TPO per il latte
Un uovo di medie dimensioni (60 gr) è costituito da
tuorlo
17 g = 29,8%
albume
33 g = 57,9%
parte non edibile
7 g = 12,3%
Guscio
8,5-10,5
Albume
60-66
Somministrare un
tuorlo significa dare
circa ¼ delle proteine
%
%
%
Lipidi
%
Glucidi
che si darebbero Minerali
Proteine
somministrando
1
4
l’albume87-89
10,7
0,4-0,5
Tuorlo
24-30
46,5-48,5
15,8
29,1
0,15-0,25
1,1-1,6
Albume +
Tuorlo
90-92
74-76
12,4
8,7
0,3-0,4
0,8-1
% Uovo
intero
% Acqua
Kcal
95
0,5-0,7
UOVO DI GALLINA
Soluzione acquosa di oltre 40 proteine, almeno 24 frazioni antigeniche diverse
ALLERGENE
NOME
Ovomucoide
Gal d1
albume
Ovoalbumina
Gal d2
albume
Ovotrasferrina
Gal d3
albume
Lisozima
Gal d4
albume
Alfa livetina
Gal d5
albume/carne/epiteli
Vitellogenina
Gal d6
tuorlo
Immunoglobuline
Gal dIgY
albume
Apovitellenina 1
Gal apovitellina I
tuorlo
Apovitellenina VI
Gal d apovitellina VI
tuorlo
Fosvitina
Gal d fosvitina
tuorlo
Ovomucina
Gal d ovomucina
albume
Etc..
PREVALENTI NEL
% albume Resistenza Resistenza Allergene
calore
enzimi
Ovomucoide
(Gal d1)
11
Stabile
Stabile
+++
Ovoalbumina
(Gal d2)
54
Instabile
Instabile
++
Ovotrasferrina
(Gal d3)
12
Instabile
Instabile
+
Lisozima
(Gal d4)
3.4
Instabile
Instabile
++
Alfa-Livetina
(Gal d5)
-
-
-
+
Vitellogenina
(Gal d6)
-
-
-
+
Da Benhamaou AH, Allergy 2010, modificata
Clinical and immunological study of allergy to hen’s egg white VI.
Occurrence of protein cross-reacting with allergens in hen’s white as
studied in egg white from turkey, duck, goose, seagull and in hen egg
yolk, and hen and chicken sera and flesh
The occurrence of proteins cross-reacting with allergens
in hen's egg white was studied in turkey, duck, goose and
seagull egg whites, in hen egg yolk, and in hen and chicken sera and flesh.
The study was based upon quantitative immunoelectrophoretic techniques.
The different egg whites were all found to contain proteins cross-reacting
with most of the allergens in hen's egg white, but the degree of crossreactivity varied considerably among the various egg whites. All egg whites
contained proteins able to bind human IgE-antibody in the sera of patients
with allergy to hen's egg white. Several proteins cross-reacting with
allergens in hen's egg white were also detected in egg yolk and in hen and
chicken sera and flesh. Clinical implications of the results are discussed.
Langeland TA, Allergy 1983;38:399–412
ANAFILASSI DA CONTATTO CUTANEO CON L’UOVO DI QUAGLIA
Caso clinico: Daniele G, bambino di 5 anni, affetto da asma, dermatite atopica e
allergico all’uovo (di gallina). Il giorno del compleanno la madre per farlo contento,
visto che non può mangiare l’uovo, gli prepara una torta con l’uovo di quaglia, che
viene reclamizzato come sicuro per i bambini allergici all’uovo di gallina. Il
bambino la aiuta in cucina, e dopo pochi minuti dall’averlo toccato manifesta
starnuti, tosse, diffocoltà respiratoria, prurito generalizzato e angioedema del viso
Bianco Gallina
Bianco Quaglia
Rosso Gallina
Rosso Quaglia
DG
Controlli allergici
all’uovo (n 15)
Controlli atopici non allergici
all’uovo (n 10)
Prick by Prick
(mm)
Prick by Prick
media (mm)
Prick by Prick
media (mm)
12
8
9
9
9,2
6,9
5,7
5,4
0
0
0
0
Alessandri C, Calvani M: Anaphylaxis to quail egg. Allergynet 2005; 60: 128
La storia “naturale”
The natural history of egg allergy
METHODS
We completed a retrospective chart review of patients with egg allergy. A total
of 4958 charts were reviewed, which yielded 881 patients with egg allergy.
Patients were included in the chart review if they had a clear clinical history of
an IgE-mediated allergic reaction to egg ingestion, or if they had an egg IgE >2
kU/L without known tolerance to egg, typically detected in the evaluation of
atopic dermatitis or other food allergies.
Savage JH, JACI 2007; 120: 1413-7
The natural history of egg allergy
Fattori di rischio per la
persistenza della allergia
all’uovo sono lo sviluppo di
asma e rinite allergica (poco la
dermatite atopica) e la presenza
di altre sensibilizzazioni
allergiche, in specie per il grano
e la soia
Savage JH, JACI 2007; 120: 1413-7
The natural history of egg allergy
I bambini che raggiungono
valori di IgE secifiche > 50
KU/l sono particolarmente a
rischio di una allergia
persistente
Savage JH, JACI 2007; 120: 1413-7
Cotto o crudo?
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Inizialmente arruolati 127 bambini (età
media 6.9 anni). Dopo il TPO 27 erano
allergici all’uovo cotto, 64 tolleravano
l’uovo cotto in matrice di grano e 23
non allergici all’uovo. Quindi 70%
(64/91) dei bambini con allergia
all’uovo tolleravano l’uovo cotto
During each oral food challenge, a
muffin and a waffle that each contained
one third of an egg (approximately 2.2 g
of egg protein) were ingested. The
muffin was baked at 350F for 30
minutes in an oven, and the waffle
(<0.625 inches thick to ensure thorough
heating) was cooked in a waffle maker
at approximately 500F for 3 minutes.
Lemon Mulè H et al, JACI 2008; 122: 977-83
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Non vi era differenza nell’impiego di
adrenalina negli allergici all’uovo
crudo o cotto.
Coloro che ricevevano adrenalina
avevano IgE specifiche per l’uovo (2.5
vs 0.7) e per l’ovomucoide (1.8 vs 0.5)
più elevate degli altri e un rapporto
IgE/IgG4 per ovomucoide più elevato.
Non c’era invece correlazione con la
gravità della reazione
Le differenze comunque non
erano tali da raggiungere un
valore predittivo in grado di
evitare il TPO
25 bambini non hanno fatto il TPO
con uovo crudo perché avevano le
IgE specifiche > ai valori predittivi
Lemon Mulè H et al, JACI 2008; 122: 977-83
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Nei bambini a dieta con uovo cotto in matrice di grano si assisteva ad
una riduzione di alcuni parametri immunologici di sensibilizzazione
allergica nei primi 3 mesi
Lemon Mulè H et al, JACI 2008; 122: 977-83
Follow-up of the Heated Egg Clinical Trial
METHODS: HE-tolerant subjects
incorporated HE into their diet and
were periodically (every >6 months)
challenged to less-heated-egg (LHE)
in the form of egg noodles and
meatballs, followed by RE. HEreactive subjects were re-challenged
to HE
Patients who were initially baked egg tolerant were 3.3 times more likely to develop
regular egg tolerance than those who were initially baked egg reactive. Patients in
the active per-protocol group were 14.6 times more likely to develop regular egg
tolerance than those in a retrospectively assessed comparison group who continued
strict avoidance of egg and more likely to develop the tolerance earlier (median 22.0
versus 66.7 months; P<0.0001). These findings suggest that the baked egg diet
accelerates the development of regular egg tolerance when compared with strict
avoidance.
Nowak-Wegrzyn A, J Allergy Clin Immunol 2011; 127:(Abstract)
Mechanisms underlying differential food
allergy response to heated egg
La cottura
Denatura gli allergeni conformazionali
Aumenta l’effetto della digestione enzimatica
(sulla ovoalbumina)
Riduce la captazione intestinale (sia ovoalbumina che
ovomucoide) e quindi la stimolazione dei basofili
Martos G et al, J Allergy Clin Immunol 2011; 127: 990-7
L’Effetto Matrice
La cottura dell’uovo a 180° c per 10 minuti insieme al grano riduce la
solubilità dell’ovomucoide. Lo stesso non avviene per la caseina.
L’immunoblotting suggerisce che l’ovomucoide formi dei polimeri e dei
complessi ad alto peso molecolare aggregandosi con il glutine, cosa che
rende meno solubile l’ovomucoide. Questo spiega perché sia necessario
in cut off più elevato per le IgE specifiche per l’ovomucoide per predire
la reattività all’uovo cotto in matrice di grano.
Kato Y, Watanabe H, Matsuda T. Ovomucoid rendered insoluble by heating
with wheat gluten but not with milk casein. Biosci Biotechnol Biochem
2000;64: 198-201
Alimenti contenenti UOVO
Ben Cotto
Torte
Biscotti
Pasta all’uovo
Barrette al cioccolato
Hamburger
Crudo
Maionese
Sorbetto
Mousse con uovo
Cottura intermedia Gelati con uovo
Frittata
Salsa tartara
Homelette
freeze-dried egg proteins
Creme caramel
Creme Brullee
Meringhe
allergenicità
Extensively heated milk and egg as oral immunotherapy
Food behavior under different heating conditions, as well as
interactions with food matrix (e.g. as seen in the case of hen’s egg
white), are highly variable among different foods, and therefore,
heating may not have similar effects for all foods. In addition,
thermal processing may not simply alter IgE epitopes, as it can
alter different biophysical and immunological properties of a food
protein such as its structure, function, solubility, digestibility, and
T-cell responses [22]. Some food proteins are rendered more
allergenic by thermal processing. For peanut proteins, high
temperature may enhance allergenicity as a result of glycation
(Maillard reaction) that induces the formation of Ara h 2
aggregates that are more resistant to gastric digestion and bind
IgE antibody more effectively than unheated Ara h 2
Huang F et al, Curr Opin Allergy Clin Immunol 2012; 12: 00
Dietary advice, dietary adherence and the acquisition of
tolerance in egg-allergic children: a 5-yr follow-up
261 bambini con diagnosi di
allergia all’uovo di cui
- 84 dopo TPO
- 131 per storia e SPT positivi
- 36 SPT positivi, mai assunto
Suggerimenti dietetici proposti
Aderenza ai
suggerimenti
Dieta senza uovo
141 (84%)
Evitare anche le
tracce
65 (39%)
Possibile la assunzione
di alimenti contenenti
uovo cotto
43 (26%)
113 (68%)
59 (35%)
33 (20%)
Allen CW et al, Pediatr Allergy Immunol 2009; 20: 213-18
Dietary advice, dietary adherence and the acquisition of
tolerance in egg-allergic children: a 5-yr follow-up
Studio
Il modo di seguire la
dieta (stretta o non) non retrospettivo
influenza il successivo
sviluppo della tolleranza
Solo circa 1/3 dei
bambini era stato
sottoposto a TPO
per l’uovo
Allen CW et al, Pediatr Allergy Immunol 2009; 20: 213-18
A longitudinal study of resolution of allergy to
well-cooked and uncooked egg
Method A longitudinal study of egg-allergic children from 2004 to 2010, who
underwent challenge with well-cooked and if negative, uncooked egg. Participants
underwent repeat annual challenges and egg-specific IgE measurement
Children with a history of a typical type-1 hypersensitivity reaction to egg
and/or skin prick weal diameter >3mm to whole egg extract and/or serum eggwhite-specific IgE >0.35 kU/L at the time of diagnosis were invited to
participate. Subjects who had never eaten egg were enrolled if they had a
positive challenge to egg and a positive SPT and/or serum-specific egg IgE
Challenges
Open challenges were either to well-cooked (sponge cake baked at 180° C for
20min), or uncooked egg (uncooked pasteurized frozen whole egg nuggets).
Five incremental doses of wellcooked (0.4 g, 0.8 g, 1.5 g, 3 g, 6 g = cumulative
dose approximately 1.0 g protein) or uncooked egg (0.5 g, 1 g, 2 g, 6 g, 12 g =
cumulative dose approximately 2.6 g protein) were ingested at 10-min intervals
Clark A et al, Cl Exp Allergy 2011; 41: 706-12
A longitudinal study of resolution of allergy to
well-cooked and uncooked egg
If a subject had tolerated wellcooked egg previously then an uncooked egg
challenge was undertaken on a separate day. All other subjects underwent a
well-cooked egg challenge initially, and if they passed went on to an uncooked
egg challenge.
La gran parte dei bambini hanno avuto solo reazioni lievi con l’uovo cotto (in matrice)
Clark A et al, Cl Exp Allergy 2011; 41: 706-12
A longitudinal study of resolution of allergy to
well-cooked and uncooked egg
The median age at which tolerance occurred was 67 months (5.6 years) for
well-cooked and 127 months for uncooked egg.
(per tollerare l’uovo crudo si impiega il doppio del tempo)
I bambini che tollerano l’uovo cotto guariscono prima dalla allergia all’uovo.
La differente tolleranza si nota già dal secondo anno di vita
Clark A et al, Cl Exp Allergy 2011; 41: 706-12
I Test Diagnostici
Premessa
PRICK TEST o “RAST”
Nelle varie casistiche della letteratura generalmente la loro
positività (> 3 mm per i prick o 1 Classe per “RAST”)
Presenta:
“BUONA SENSIBILITÀ E
VALORE PREDITTIVO NEGATIVO”
(individuiamo la gran parte dei malati)
“BASSA SPECIFICITÀ E
VALORE PREDITTIVO POSITIVO”
(il test risulta spesso positivo nei soggetti sani)
Egg challenge in children with atopic dermatitis
Disegno: Studio prospettico
che ha arruolato 107
bambini con dermatite
atopica che non avevano
mai ingerito l’uovo.
Il TPO effettuato all’età
mediana di 15 mesi è risultato
positivo in 72/107 (67,3%). Di
questi 56/72 (77.8%) erano
reazioni immediate, le restanti
ritardate
Uno SPT positivo di 5 mm presenta il 100% di specificità per un TPO positivo
Monti G et al, Cl Exp Allergy 2002; 32: 1515-19
Skin prick test predictive value on the outcome of a first
known egg exposure in milk-allergic children
Children under the age of 1 yr who came consecutively to
Allergy Department 2003–05, and were diagnosed with
IgE mediated milk allergy were selected for this study.
Egg introduction was completely avoided until the age of
14 months when clinical history, skin prick tests (SPT),
specific-IgE antibodies determination and egg challenge
test were performed
Dieguez MC et al, Pediatr Allergy Immunol 2008; 19: 319-23
Skin prick test predictive value on the outcome of a first
known egg exposure in milk-allergic children
One hundred and four
patients were included in
the cohort, 31 (30.4%)
had at least one atopic
parent, 60 (59.4%) had
atopic dermatitis 17
(16.3%) had asthma and
52 (50%) had positive
prick test to other tested
foods (fish, nuts, apple,
peach, melon or lentils).
Gl allergici all’uovo hanno più frequentemente la dermatite atopica e
multiple sensibilizzazioni ad alimenti
Dieguez MC et al, Pediatr Allergy Immunol 2008; 19: 319-23
Skin prick test predictive value on the outcome of a first
known egg exposure in milk-allergic children
Il bianco dell’uovo e l’ovomucoide
presentano la migliore area sotto la
curva. Il bianco dell’uovo la migliore
sensibilità e l’ovomucoide la migliore
specificità
Il Cut-off ottimale (che
combina la migliore
sensibilità e specificità)
è 6 mm per l’albume e
5 mm per l’ovomucoide
Dieguez MC et al, Pediatr Allergy Immunol 2008; 19: 319-23
Livelli di IgE specifiche (Cap System) proposti come Cut off diagnostici
per l’uovo e relativo potere predittivo positivo
Autore
n.
Età
DA
(%)
Allergia
all’uovo
(%)
(preval)
Cut off
PPV
90%
Cut off
PPV
95%
Cut off
PPV
99%
Metodo
Sampson
1997
196
5.2 anni
(media)
100
73
2
6
nd
ROC
Sampson
2001
100
3.8 anni
(mediana)
60
80
nd
7
nd
ROC
Boyano
Martinez
2001
81
16 mesi
(media)
43
79
nd
0,35*
Osterballe
2003
56
2,3 anni
(mediana)
100
64
CelikBilgili
2005
992
13 mesi
(mediana)
†
88
30
6,3 ‡
Mehl
2006
437
13 mesi
(mediana)
90
29
Kamata
2007
764
1.3 anni
(mediana)
74
49
ROC
1,5^
ROC
12,6
59,2
RL
nd
15,9
75,5
RL
nd
25.5
nd
RL
Calvani M, Zappala D, Panetta V, Prospettive in pediatria 2007; 37: 165-72
The predictive value of skin prick testing for
challenge-proven food allergy: A systematic review
Peters RL et l, Pediatr Allergy Immunol early online
ImmunoCAP
Code
Name
Latin name
f76
nBos d 4 α-lactalbumin, Milk
Bos domesticus
f77
nBos d 5 β-lactoglobulin,
Milk
Bos èdomesticus
Con l’immunoCap
oggi
e204
possibile
nBos d 6 Serum albumin,
Milk
f78
f334
la diagnostica
Bos domesticus
molecolare solo
nei
nBos d 8 Casein, Milk
Bos domesticus
confronti di 3 molecole
nBos d Lactoferrin, Milk
Bos domesticus
dell’uovo
f233
nGal d 1 Ovomucoid, Egg
Gallus domesticus
f232
nGal d 2 Ovalbumin, Egg
Gallus domesticus
f323
nGal d 3 Conalbumin, Egg
Gallus domesticus
f355
rCyp c 1 Carp
Cyprinus carpio
f426
rGad c 1, Cod
Gadus morhua
f351
rPen a 1 Tropomyosin, Shrimp
Penaeus aztecus
Da www.Phadia.com, accesso il 16 maggio 2012
ISAC: Ricerca 112 molecole allergeniche contenute in 51 sostanze
Mentre con l’ISAC è possibile
ricercare 4 molecole dell’uovo
(il Gal d1, Gal d2, il Gal d3 e il
Gl d5)
Clinical usefulness of microarray-based IgE detection in
children with suspected food allergy
Background:.. The aim of this study was
to evaluate the utility of microarraybased IgE detection in the diagnostic
workup of food allergy and to compare
this new diagnostic tool with established
methods of allergen-specific IgE
detection.
Methods: We investigated 130 infants
and children with suspected allergy to
cows milk (CM) or hens egg (HE).
Serum IgE measurements, skin prick
tests, allergen microarray assays and
controlled oral food challenges with HE
and CM were performed. During 145
oral provocations, oral application of HE
induced clinical symptoms in 45 out of
60 individuals (75%). (uovo crudo)
Ott H et al, Allergy 2008; 63: 1521-8
Clinical usefulness of microarray-based IgE detection in
children with suspected food allergy
Comparison of FEIA results with each single
microarray component by nonparametric
Wilcoxon testing revealed no statistically
significant differences between AUC values…
One single allergen component i.e. Gal d 1
generated similar AUC results as the
respective microarray component combination
or FEIA testing while highest AUC values
were obtained by SPT with native HE
preparations.
The combination of all allergen microarray
results generated the same or highly similar
AUC values as compared to FEIA testing in
HE allergy diagnosis.
Ott H et al, Allergy 2008; 63: 1521-8
Clinical usefulness of microarray-based IgE detection in
children with suspected food allergy
In conclusion, allergen microarrays provide a new tool to diagnose symptomatic CM and
HE allergy. They show performance characteristics comparable to the current diagnostic
tests and may be indicated in small children in whom only small blood volumes are
obtainable. However, they are not capable of replacing double-blind, placebo-controlled
food challenges in most cases.
Ott H et al, Allergy 2008; 63: 1521-8
Utility of ovomucoid-specific IgE concentrations in
predicting symptomatic egg allergy
Background: Children with allergy to raw egg white might tolerate low amounts of
heated egg. Ovomucoid-specific IgE antibodies have been suggested to be predictors
of whether children could tolerate heat-treated egg.
Methods: One hundred eight patients (median age, 34.5 months) with suspected egg
allergy underwent double-blind, placebocontrolled food challenges with raw and
heated egg. The outcomes of the challenges were related to the serum concentration
of specific IgE antibodies and total IgE by using ImmunoCAP.
Subjects Patients (male/female ratio, 67/41) had mostly atopic dermatitis, asthma, and,
in a few cases, gastrointestinal symptoms and anaphylaxis. The patients were divided
into 3 groups on the basis of their immediate reactions to oral provocation tests.
Group A (n 38) had positive challenge results for heated egg white (the subjects were
considered reactive to both heated and raw egg white) ,(Allergici all’uovo cotto e crudo)
Group B (n 29) consisted of subjects who had positive reactions to raw egg white but
negative reactions to heated egg white, and (allergici all’uovo crudo ma non cotto)
Group C (n 41) consisted of subjects who had negative responses to both raw and heated
egg white. (non allergici all’uovo)
Uovo cotto: bollito 60 minuti a 90o
Ando H et al, J Allergy Clin Immunol 2008; 122: 583-8
Utility of ovomucoid-specific IgE concentrations in
predicting symptomatic egg allergy
Le Ige specifiche per il bianco di
uovo riescono meglio di quelle per
la ovoalbumina e l’ovomucoide a
differenziare i pazienti allergici
all’uovo crudo rispetto ai tolleranti.
Le IgE specifiche per l’ovomucoide
differenziano meglio gli allergici all’uovo
cotto rispetto ai tolleranti. Il Cut off
ottimale è 4.40 kUA/L, che corrisponde ad
una sensibilità del 76% e a una specificità
dell’ 81%.
Ando H et al, J Allergy Clin Immunol 2008; 122: 583-8
Utility of ovomucoid-specific IgE concentrations in
predicting symptomatic egg allergy
DISCUSSION: This study
demonstrates that quantitative
measurements of specific IgE
antibodies, both toward egg white
and ovomucoid, are useful in the
management of children with egg
allergy. Specific IgE antibody levels
to egg greater than 7 kUA/L were
highly indicative of allergy toward
raw egg, whereas specific IgE
antibodies to ovomucoid greater than
11 kUA/L were indicative for allergy
toward heated egg white.
Questi “decision point” sono stati individuati con il livello delle IgE che
rappresenta il 95% della specificità del test, valore che non dipende dalla
prevalenza della malattia nella popolazione
Ando H et al, J Allergy Clin Immunol 2008; 122: 583-8
Performance of a component-based allergen-microarray in the
diagnosis of cow’s milk and hen’s egg allergy
Methods. One-hundred and four children with suspected IgE-mediated
hypersensitivity to CM or HE were studied. In all patients, skin prick test,
ImmunoCAP, microarray and FCT were performed. The FCT material
was cooked egg (boiled for 10 min) or raw egg in the case of negative FCT
to cooked egg.
Results The microarray components Gal d 1 (20/46 patients) and Gal d 2
(24/46) for HE were the most frequently recognized allergens. Using the
FCT results as the reference parameter, sIgE to Gal d 1 had the highest area
under the curves. These were not significantly different from those obtained
using the ImmunoCAP. Use of 95% clinical decision points (CDP) for sIgE
to Gal d 1 resulted in higher negative predictive values (79%) than those
obtained with the ImmunoCAP (59%).
D’Urbano Le et al Clin Exp Allergy 2010; 40: 1561-70
Performance of a component-based allergen-microarray in the
diagnosis of cow’s milk and hen’s egg allergy
il Gal d1 ha la
migliore area sotto la
curva. La prestazione
è lievemente
superiore al semplice
CAP per l’uovo.
D’Urbano Le et al Clin Exp Allergy 2010; 40: 1561-70
Performance of a component-based allergen-microarray in the
diagnosis of cow’s milk and hen’s egg allergy
Lo studio non distingue gli
allergici all’uovo cotto da quelli
all’uovo crudo e calcola le
performance diagnostiche sulla
popolazione complessiva. Il
95% CDP è stato ricavato
mediante regressione logistica
In suspected HE allergy, the best performance was obtained using sIgE levels
to Gal d 1, with the microarray. While use of 95% CDP for sIgE to egg white,
measured with ImmunoCAP, would have eliminated the need of the FCT in
approximately 15%, the use of 95% CDP for Gal d 1 sIgE would have led to a
37% reduction, and to a reduction in positive FCT (6 vs. 16).
D’Urbano Le et al Clin Exp Allergy 2010; 40: 1561-70
Ovomucoid (Gal d 1) specific IgE detected by microarray system predict
tolerability to boiled hen’s egg and an increased risk to progress to
multiple environmental allergen sensitisation
Study population
The studied population was
represented by 68 children (47 male,
69.1%), age ranging from 1 to 11
years (median 4.1 years), referring to
our centre by the family
paediatricians for suspected HE
allergy. Patients underwent doubleblind, placebo-controlled food
challenge with boiled and raw eggs.
Popolazione “poco allergica”:
ben 35/68 era SPT negativi
per l’uovo
Uovo sodo (cotto 10 minuti a 100°)
Alessandri C et al, Cl Exp Allergy 2012; 42: 441-50
Ovomucoid (Gal d 1) specific IgE detected by microarray system predict
tolerability to boiled hen’s egg and an increased risk to progress to
multiple environmental allergen sensitisation
The best performance on the analysed ROC curve,
using as gold standard the raw and boiled egg DBPCFC,
was provided by the boiled white SPT (Fig. 1), with a
criterion set at >11.6 mm2.
Alessandri C et al, Cl Exp Allergy 2012; 42: 441-50
Ovomucoid (Gal d 1) specific IgE detected by microarray system predict
tolerability to boiled hen’s egg and an increased risk to progress to
multiple environmental allergen sensitisation
Lo SPT per uovo cotto e il Gal D1 presentano il miglior rapporto di
verosimiglianza per la diagnosi di allergia all’uovo cotto
Alessandri C et al, Cl Exp Allergy 2012; 42: 441-50
Il Test di Provocazione Orale
Caratteristiche dei test di provocazione orale per alimenti
in Italia. Studio retrospettivo multicentrico
783 TPO effettuati in 6 centri italiani
Berti I et al, RIAP 2010; 3: 8-14
Oral food challenges in children are safe and severe reactions
are almost all due to respiratory symptoms.
Methods. A retrospective
charts review was performed
in children who underwent
food challenges in 3 Allergy
Clinics in Italy.... Children
were referred to the Clinics
primarily because they had a
positive history of reactions to
food and/or detectable
specific IgE. Children already
diagnosed as allergic and rechallenged to test the
persistence of the allergy
were also included.
Calvani M et al, submitted
Oral food challenges in children are safe and severe reactions
are almost all due to respiratory symptoms.
There were 254 (48.3%) positive OFCs out of a total of 526
challenges. OFCs with egg were more commonly positive than
OFCs to all other foods combined (p = 0.002).
Egg challenges were conducted mainly with raw egg (192/218;
88%) but also with heated egg (26/218; 12%).
Within egg challenges, challenges with raw egg were more
commonly positive (116/192; 60.4%) than with heated egg
(7/26; 26.9%)(P = 0.001).
Calvani M et al, submitted
Anaphylactic reactions to raw eggs after
negative challenges with cooked eggs
These reports and our observations raise several questions of
importance to the clinician. Should we do follow-up challenges
for egg hypersensitivity with raw eggs exclusively? On the other
hand, should we continue to challenge with cooked eggs? More
studies will be necessary to answer these questions. In the
meanwhile, we suggest mixing freeze-dried egg with oatmeal or
with any other food tolerated by the patient. If the patient does
not become tolerant in a “reasonable” follow-up time period, we
would recommend testing cooked eggs to allow a diversification
of the diet.
Eigenmann P, J Allergy Clin Immunol 2000; 105: 587-8
Grazie per l’attenzione e..
Arrivederci a Diari ver 2.012
(25-27 ottobre 2012, Roma)
Chicken serum albumin (Gal d 5*) is a partially heat-labile
inhalant and food allergen implicated in the bird-egg syndrome
Disegno: 8 pazienti con sintomi respiratori (rinite o asma) in seguito alla inalazione di
piuma di uccello e alla ingestione di tuorlo di uovo sono stati studiati per confermare il
ruolo causale della alfa-livetina nei sintomi riferiti
Risultati: tutti presentavano IgE specifiche per il tuorlo e per la alfa-livetina mentre
erano frequentemente negativi per il bianco, l’ovoalbumina e l’ovomucoide.
Il test di provocazione bronchiale con alfa-livetina
causava la rapida insorgenza di una crisi asmatica
in tutti i soggetti che soffrivano di asma.
Quirce S et al, Allergy 2001; 56: 754-62
Fattori clinici e di laboratorio che sono stati associati allo
sviluppo di tolleranza per l’uovo sono
Sintomi lievi alla ingestione
Ridotte dimensioni degli SPT
Ridotti livelli di IgE specifiche
Precoce età alla diagnosi
Percentuale di riduzione nel
tempo delle IgE specifiche
Ford RP et al Arch Dis Child 1982
Boyano-Martınez T J Allergy Clin Immunol 2002
Dannaeus A Clin Allergy 1981
Shek LP, J Allergy Clin Immunol 2004
Shek LP, J Allergy Clin Immunol 2004
Oral Food Challenges in Children with a Diagnosis of Food Allergy
Conclusions. In the absence of anaphylaxis, the primary reliance on serum foodspecific IgE testing to determine the need for a food elimination diet is not
sufficient, especially in children with atopic dermatitis. In those circumstances,
oral food challenges may be indicated to confirm food allergy status
Fleischer MD et al, J Pediatr 2011; 158: 678-83
Serum ovalbumin-specific immunoglobulin G responses during
pregnancy reflect maternal intake of dietary egg and relate to the
development of allergy in early infancy
Objectives: To monitor egg intake during a randomized controlled trial of egg avoidance
throughout pregnancy and lactation by serial measurements of serum ovalbumin (OVA)
IgG concentration in conjunction with dietary diary record and also, to analyse specific IgG
concentrations at birth in relation to infant allergic outcome.
Methods: Pregnant women, with personal or partner atopy, were randomized to complete
dietary egg exclusion or an unmodified healthy diet before 20 weeks gestation. The
infants were examined carefully for signs of allergic disease and at 6, 12 and 18 months
of age they were skin prick tested to a panel of common dietary and inhalant allergens
(raw cow milk, whole egg, egg white, egg yolk, peanut, HDM, cat, timothy grass pollen,
birch pollen: ALK).
Vance GHS, et al, Cl Exp All 2004; 34: 1855-61
Risultati: An atopic phenotype, as defined by atopic dermatitis and/or positive SPT,
was identified in 47%, 55% and 42% of these infants at 6, 12 and 18 months of
age, respectively. There was no difference in the number of infants born to eggavoiding, as compared with control, mothers who developed an allergic phenotype
over the first 18 months of life.
Vance GHS, et al, Cl Exp All 2004; 34: 1855-61
Highly accurate prediction of food challenge outcome using
routinely available clinical data
La gravità della reazione clinica precedente è il fattore di rischio più
importante per la positività del successivo TPO
DunnGalvin A et al, JACI 2011; 127: 633-39
Reazioni durante il TPO nella letteratura
Autore
TPO
(n)
TPO pos
(%)
Sintomi
respiratori
# (%)
Sintomi
cardiovascolari
(%)
Adrenalina
(%)
Reibel, 2000
349
51
2.8
0
?
Perry, 2004
584
43
26
0
11
Mankad, 2008
150
27
8
0
0
Jarvinen, 2009
1273
34
0
0
11
Lieberman, 2011*
701
18.8
2.2
0
9
Calvani submitted
526
48.3
20.4
0
0.4
# sintomi del laringe o delle basse vie
* popolazione a rischio relativamente basso di allergia
A new model for low-dose food challenge in children
with allergy to milk or egg
Background: Atopic eczema and food allergy are common in early childhood.
Children seem to gradually develop tolerance to milk and egg, and it is a relief
for families when their child can tolerate small amounts of these basic foods,
even if larger doses may still cause symptoms.
Aim: To develop a model for low-dose oral food challenge, facilitating re/introduction of milk or egg.
Methods: In 39 children sensitized to milk and/or egg, we performed 52
challenges using a new standardized model for low-dose oral food challenge
Increasing doses of the allergen were given in amounts
of 0.1, 0.5, 5.0, 15 and 30 ml for milk and 0.1, 0.5,
1.5, 5 and 10 g (di un dolce preparato con uovo) for egg.
Devenney I et al, Acta Paaediatrica 2006; 95: 1133-39
A new model for low-dose food challenge in children
with allergy to milk or egg
Outcome of food challenge
In 4/52 challenges the results were positive, with immediate allergic
symptoms. All four children had a family history of allergy. They were
subjected to DBPCFC to milk and reacted on the first to third dose
administered. One child had a negative SPT at the time of the challenge but
expressed an SPT of 10.5 mm when re-tested 2 wk after the challenge.
Post food challenge follow-up
At the 3-mo follow-up, three of the four children with a positive
challenge outcome were still on a milk and egg-free diet. At its parents’
initiative, one child (child 1, Table III) had received small amounts of
milk in its diet without problems. All but two of the non-reacting infants
had successfully introduced the food into their diet without reactions.
Devenney I et al, Acta Paaediatrica 2006; 95: 1133-39
Epinephrine treatment is infrequent and biphasic reactions are rare in
food-induced reactions during oral food challenges in children
Le reazioni al challenge che richiedevano Adrenalina si verificano più spesso nei
bambini di età più elevata e se allergici alle arachidi. Il Sesso, la storia di
anafilassi o di asma o i valori delle IgE specifiche non erano fattore di rischio
Jarvinen KM et al, J Allergy Clin Immunol 2009; 124: 1267-72
Parental anxiety before and after food
challenges in children with suspected peanut
and hazelnut allergy
The goal of this study was to assess (i) parental anxiety about food-allergic
reactions in their child and (ii) the association between a doubleblind
placebo-controlled food challenge (DBPCFC) and parental anxiety about
foodallergic reactions in their child.
Psychological measures
We used the Spielburger State-Trait Anxiety Inventory (STAI), Dutch
Version (17), to assess two types of anxiety: state anxiety (transient
emotional condition, in this study anxiety about a food-allergic reaction)
and trait anxiety (disposition indicating anxiety proneness).
Zijlstra WT et al, Pediatr Allergy Immunol 2009; 1-7
What safety measures need to be taken in oral food
challenges in children?
Methods: We retrospectively evaluated 349 oral challenges in 204 children with
atopic dermatitis, looking for criteria to help the physician decide which patients
need medical intervention.
Of the 178 (51%) positive provocations, 120 (67%) subjects needed medical
intervention, and 58 (33%) had a positive challenge but needed no medication.
In 42 (23%) food challenges, medical intervention was parenteral, and oral
medication was given in 78 (43%) cases (Fig. 1).
Reibel S et al, Allergy 2000; 55: 940-4
Risk of oral food challenges
Metodi: analisi retrospettiva delle cartelle dei bambini sottoposti a test di
scatenamento orale per alimenti in un periodo di 7 anni
Popolazione: di 584 challenge, 253 (43%) hanno dato esito ad una reazione
allergica. In particolare per quanto riguarda il latte, 90/161 (56%) sono falliti
(reazione allergica)
Briefly, challenges were administered in escalating doses every 15 minutes
until 4 g (<5 years old) or 8 g (5 years old) of food protein was ingested. The
challenge was terminated when objective symptoms were noted by the
practitioner or subjective symptoms such as abdominal pain worsened during
the challenge.
Perry TT et al, JACI 2004; 114: 1164-8
Risk of oral food challenges
Le reazioni gravi si verificano con le prime dosi di latte
That severe allergic reactions occur during OFC is not in doubt, and the
procedure must take place in appropriately staffed children’s units with
adequate resuscitation facilities. Such reactions appear to be treated
effectively without harmful effects to the patient, with no cases of very
severe or fatal allergic reactions identified in a two year period
Is this apparently reassuring finding a reflection of our reluctance to
investigate children when the tests may put them at risk?
Perry TT et al, JACI 2004; 114: 1164-8
Safety of open food challenges in the office setting
Challenges were judged positive and terminated at the first sign of a convincing
clinical reaction, resulting in objective findings based on the judgment of the
practitioner administering the challenge. Conclusion: Open food challenges are
a safe procedure in the office setting for patients selected based on history and
food specific IgE approaching negative predictive values
Mankad VS et al, Ann Allergy Asthma Immunol 2008; 100: 469-74
Outcomes of office-based, open food challenges
in the management of food allergy
. The OFCs were performed in the outpatient setting by a trained nurse or
physician (while the supervising physician was on site at all times) per
guidelines established by the current Working Group on Food Challenges
report, with most challenges using doubling doses every 15 minutes until
an age-appropriate serving size was administered. …. The majority of
reactions, 56.8%, were cutaneous. All but 16 reactions (87.9%) were
treated with antihistamine alone. Twelve reactions were treated with
epinephrine (including one that required 2 doses of epinephrine), 7 with
prednisolone, and 2 with albuterol (Table III). All but one reaction was
managed in the office setting; 1 patient was transferred to the emergency
department for monitoring and intravenous fluids due to persistent
vomiting following a challenge to peanut.
Lieberman JA et al, JACI 2011, in press


Urisu A, Ando H, Morita Y, et al.
Allergenic activity of heated and
ovomucoiddepleted
egg white. J Allergy Clin Immunol
1997; 100:171–176.
Risk factors for severe pediatric food anaphylaxis in Italy
Calvani M et al, Pediatr Allergy Immunol 2011, in press
Cotto o crudo



Ben cotto (180° x 20 min)(sponge cake baked)
(Clark 2011)
Cotto (bollito 60’ a 90° (Ando 2008)
Cotto (bollito 10’ a 100° (Alessandri 2011)
Molecular diagnosis of egg allergy
Conclusion
Molecular diagnosis technologies will improve diagnosis
of IgE-mediated egg allergy. .. Component-resolved diagnosis based on a
microarray platform is especially promising. None of these molecular-based
tests is ready to be used in clinical practice and an oral food challenge will
still be necessary in many patients for the diagnosis of egg allergy.
Cauet JC et al, Curr Opin Allergy Clin Immunol 2011; 11: 210-5
Nicola, 14 anni
Affetto da rinite primaverile da graminacee, polisensibiizzato a pollini ed
epiteli di animali, in trattamento da 2 anni, con giovamento, con vaccino
desensibilizzante per graminacee.
Riferisce che da circa 4 anni ha iniziato a presentare dei sintomi,
progressivamente ingravescenti di prurito orale, “saliva densa”, fastidio alla
gola che si protraggono per circa ½ ora, che insorgono subito dopo aver
assunto il pollo. Per tale motivo da circa 2 anni ha smesso di assumerlo. Tali
sintomi si sono presentati in modo importante inoltre in seguito alla
assunzione di una fettina di tacchino, che quindi non ha più assunto. Si
presentano invece in forma lieve quando mangia dei wurstel di maiale, non
se i wurstel vengono cotti bene, e per questo motivo ancora li assume.
Assume invece abitualmente e senza alcun disturbo l’uovo, in tutte le forme.
Da 2 anni inoltre ha iniziato a presentare una analoga sintomatologia, in più
occasioni, subito dopo aver mangiato del tonno e anche del merluzzo, che
quindi ha smesso di mangiare, mentre assume senza problemi altri pesci,
quali spigola, orata e anche i crostacei e i molluschi.
Gli accertamenti eseguiti
CAP
Pollo: 1.6 ku/l
Tacchino: 0.78
Albume: neg
Tuorlo: neg
SPT
Albume: 1 mm
Tuorlo: 2 mm
Pollo: 6 mm
Maiale: 3 mm
Merluzzo: 5 mm
Tonno: 4 mm
Sardina: 4 mm
Gambero: neg
Mitili: neg
Istamina: 6 mm
Controllo: neg
UOVO DI GALLINA
Soluzione acquosa di oltre 40 proteine, almeno 24 frazioni antigeniche diverse
ALLERGENE
PREVALENTI NEL
NOME
PM (kd)
AA
Ovomucoide
Gal d1
28
186
albume
Ovoalbumina
Gal d2
66-70
385
albume
Ovotrasferrina
Gal d3
77
686
albume
Lisozima
Gal d4
14.3
129
albume
Ovomucina
Gal d ovomucina
albume
Alfa livetina
Gal d5
albume/tuorlo/carne/epiteli
Immunoglobuline Gal dIgY
albume
Apovitellenina 1
tuorlo
Gal apovitellina I
Apovitellenina VI Gal d apovitellina VI
Fosvitina
Etc..
Gal d fosvitina
tuorlo
tuorlo
Peculiarities of egg allergy in children with bird
protein sensitization
Disegno: gli autori hanno seguito prospetticamente per 4 anni 27 bambini con allergia
all’uovo e alle piume di uccello o alla carne di pollo e 19 controlli con sola allergia
all’uovo, per valutare se vi erano differenze nella evoluzione clinica.
Risultati: i bambini con allergia
all’uovo e alle piume hanno una
prognosi peggiore, per la maggior
durata della allergia, la più
frequente presenza di sintomi
respiratori e gastrointestinali. Si
differenziano dai controlli anche
per il persistere e l’aumentare delle
IgE specifiche per il tuorlo
dell’uovo
La Egg-bird o la Bird-egg Syndrome è dovuta alla alfa-livetina (Gal d5)
Bausela BA et al, Ann Allergy Asthma Immunol 1997; 78: 213-6
Food allergy to chicken meat with IgE reactivity to
muscle -parvalbumin
We report the case of a 54-year-old patient who experienced severe allergic
reactions to poultry products. Swelling of tongue and oral mucosa,
vomiting and hypotension occurred a few minutes after ingestion of
chicken meat, turkey meat or chicken both. The patient reported mild oral
reactions when eating tuna and salmon. The patient tolerated chicken eggs.
Skin prick tests (SPT) performed with a series of commercial aeroallergens
(ALK, Varennes en Argonne, France) were positive for tree and grass
pollen. Skin prick tests with food allergens were positive with chicken
meat, turkey meat and different fishes (tuna, salmon, cod and carp).
Kuehn A et al, Allergynet 2009; 64: 1554-61
Food allergy to chicken meat with IgE reactivity to
muscle -parvalbumin
The total IgE level was 80 kU/l (Phadia ImmunoCAP System, Uppsala,
Sweden). Specific IgE were positive for chicken meat (12 kU/l), turkey
meat (6 kU/l), pork meat (1 kU/l), cod (3 kU/l), tuna (3 kU/l) and salmon (2
kU/l), but negative for egg yolk and egg white (<0.35 kU/l).
Protein sequence analysis of a-parvalbumins
showed that chicken parvalbumin was 100%
identical to turkey, 83% to cattle/horse, 82%
to frog, 80% to pig, 79% to human (X63070)
and 54% to cod b-parvalbumin. IgE bind
specifically to purified native (3) and
recombinant (4) chicken a-parvalbumin, but
not to tuna (5) b-parvalbumin
Kuehn A et al, Allergynet 2009; 64: 1554-61
Identification of Allergens in Chicken Meat Allergy
A 20-year-old man experienced oropharyngeal and palmar itching, facial
hives, lip swelling, dysphagia, dyspnea, and heartburn 15 minutes after eating
chicken. He tolerated turkey, but did not eat any other poultry meat or meats
such as veal, pork, and rabbit. He tolerated eggs and had no contact with birds
The analysis of the resulting
peptides by mass spectrometry or
MS/MS identifi ed the 16-kDa band
as α-parvalbumin and the 27-kDa
band as myosin light chain 1 (MLC).
We present a patient with IgEmediated allergy to chicken
meat and no sensitization to egg
proteins. α-Parvalbumin and myosin
were identified as the relevant
allergens
Gonzalez-Manchebo E et al, J Invest Allergol Clin Immunol 2011; 21: 317-19
Identification of Allergens in Chicken Meat Allergy
α-Parvalbumin is abundant in the muscle of fish and amphibians, rather less
so in birds and mammals, and is not generally described as allergenic,
except for a case of allergy to frog meat [6] and a case of allergy to poultry
meat [4]. ß-Parvalbumin, which does not usually cross-react with
α-parvalbumin [7], has been described as a major allergen and as the most
important allergen in many fish species Myosins are a large superfamily of
motor proteins that move along actin filaments while hydrolyzing
adenosine triphosphate.
Two light chains of muscle myosin, each measuring 20 kDa, wrap around
the neck region of the 2 myosin heavy chains [8]. Although shrimp MLC
(Lit v 3) has been identifi ed as a new major shrimp allergen [8], MLC has
never been described as an allergen in chicken meat.
Gonzalez-Manchebo E et al, J Invest Allergol Clin Immunol 2011; 21: 317-19
Tolerance to extensively heated milk in
children with cow’s milk allergy
100 bambini di 6 mesi-21 anni
(media 7.5 anni) con SPT o IgE
specifiche per latte e storia di
reazione entro 6 mesi o valori
superiori ai cut-off consigliati
68/100 bambini
tolleravano il latte cotto in
matrice di grano
Ciascun muffin e waffle
contenevano 1.3 gr di
proteine del latte. Il TPO
consisteva nella
somministrazione di 1
muffin e 1 waffle (2.6 gr)
Muffin cotto a 350°F (176° celtius) per 30 minuti
Waffle cotto a 500° F (260° celtius) per 3 minuti
Nowak Wegrzyn A et al, J Allergy Clin Immunol 2008
Tolerance to extensively heated milk in
children with cow’s milk allergy
Tutti i bambini con
negatività delle IgE
specifiche o SPT < 5 mm
per il latte tolleravano il
latte cotto
8/23 dei bambini che
hanno reagito al latte cotto
hanno sviluppato anafilassi
contro 0/41 di quelli che
reagivano al latte non cotto
Nowak Wegrzyn A et al, J Allergy Clin Immunol 2008
Tolerance to extensively heated milk in
children with cow’s milk allergy
Dopo 3 mesi di continua
assunzione degli alimenti
contenenti latte cotto si
assisteva ad una significativa
riduzione del diametro del
pomfo per il latte e ad un
aumento delle IgG4 per la
caseina
.. our findings suggest that ingestion of heated milk is associated with responses
to casein and b-lactoglobulin that favor development of tolerance.
Nowak Wegrzyn A et al, J Allergy Clin Immunol 2008
Dietary baked milk accelerates the
resolution of cow’s milk allergy in children
Dei 65 bambini che hanno tollerato
il latte cotto,
- 39 (60%) tolleravano anche il latte
non cotto dopo 5 anni di follow-up
- 8 (12%) decidevano di tornare a
dieta senza latte
- 5 riferivano sintomi alla ingestione
di prodotti meno cotti
- 2 hanno avuto sintomi al challenge
con latte non cotto
- 1 ha avuto una reazione alla
ingestione di un uovo con
mozzarella
- 2 hanno avuto sintomi orali alla
ingestione di pizza poco cotta
Kim SK et al, JACI 2011; 128: 125-131
Dietary baked milk accelerates the
resolution of cow’s milk allergy in children
In the per-protocol group (n = 70) the
probability of having unheated milk
tolerance within 60 months was 76%. In
the comparison group (n = 60) this
probability was 33%
Tolerance of baked milk is a marker of transient IgE-mediated cow’s milk allergy,
whereas reactivity to baked milk portends a more persistent phenotype. The addition
of baked milk to the diet of children tolerating such foods appears to accelerate the
development of unheated milk tolerance compared with strict avoidance
Kim SK et al, JACI 2011; 128: 125-131
Differenze immunologiche nei soggetti con allergia al latte cotto in matrice o crudo
Jarvinen KM, JACI 2001
Schreffler WG, JACI 2009
Wanich N, JACI 2009
Wang J, JACI 2010
Caubet , submitted
Five IgE-binding epitopes were not recognized by any of the
patients with transient milk allergy but showed binding by the
majority of the patients with persistent allergy.
A higher percentage, 16.85% (7.1–31.7)] of proliferating
allergen-specific CD25+CD27+ T cells from cultures of
heated milk-tolerant children [4.91% (2.6–7.5)] than those
with allergy.
Heated milk-tolerant individuals’ basophils were significantly
less responsive to milk allergen stimulation at all doses than
were basophils from heated milk-reactive individuals
Children with milk allergy had increased epitope diversity
compared with those who outgrew milk allergy.
levels of IgE to cow’s milk, casein and b-lactoglobulin were
significantly higher in baked milk-reactive patients compared
with baked milk-tolerant patients
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Inizialmente arruolati 127 bambini (età
media 6.9 anni). Dopo il TPO 27 erano
allergici all’uovo cotto, 64 tolleravano
l’uovo cotto in matrice di grano e 23
non allergici all’uovo. Quindi 70%
(64/91) dei bambini con allergia
all’uovo tolleravano l’uovo cotto
During each oral food challenge, a
muffin and a waffle that each contained
one third of an egg (approximately 2.2 g
of egg protein) were ingested. The
muffin was baked at 350F for 30
minutes in an oven, and the waffle
(<0.625 inches thick to ensure thorough
heating) was cooked in a waffle maker
at approximately 500F for 3 minutes.
Lemon Mulè H et al, JACI 2008; 122: 977-83
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Non vi era differenza nell’impiego di
adrenalina negli allergici all’uovo
crudo o cotto.
Coloro che ricevevano adrenalina
avevano IgE specifiche per l’uovo (2.5
vs 0.7) e per l’ovomucoide (1.8 vs 0.5)
più elevate degli altri e un rapporto
IgE/IgG4 per ovomucoide più elevato.
Non c’era invece correlazione con la
gravità della reazione
Le differenze comunque non
erano tali da raggiungere un
valore predittivo in grado di
evitare il TPO
25 bambini non hanno fatto il TPO
con uovo crudo perché avevano le
IgE specifiche > ai valori predittivi
Lemon Mulè H et al, JACI 2008; 122: 977-83
Immunologic changes in children with egg
allergy ingesting extensively heated egg
Nei bambini a dieta con uovo cotto in matrice di grano si assisteva ad
una riduzione di alcuni parametri immunologici di sensibilizzazione
allergica nei primi 3 mesi
Lemon Mulè H et al, JACI 2008; 122: 977-83
Follow-up of the Heated Egg Clinical Trial
METHODS: HE-tolerant subjects
incorporated HE into their diet and
were periodically (every >6 months)
challenged to less-heated-egg (LHE)
in the form of egg noodles and
meatballs, followed by RE. HEreactive subjects were re-challenged
to HE
Patients who were initially baked egg tolerant were 3.3 times more likely to
develop regular egg tolerance than those who were initially baked egg reactive.
Patients in the active per-protocol group were 14.6 times more likely to develop
regular egg tolerance than those in a retrospectively assessed comparison group
who continued strict avoidance of egg and more likely to develop the tolerance
earlier (median 22.0 versus 66.7 months; P<0.0001). These findings suggest that
the baked egg diet accelerates the development of regular egg tolerance when
compared with strict avoidance.
Nowak-Wegrzyn A, J Allergy Clin Immunol 2011; 127:(Abstract)
L’Effetto Matrice
La cottura dell’uovo a 180° c per 10 minuti insieme al grano riduce la
solubilità dell’ovomucoide. Lo stesso non avviene per la caseina.
L’immunoblotting suggerisce che l’ovomucoide formi dei polimeri e dei
complessi ad alto peso molecolare aggregandosi con il glutine, cosa che
rende meno solubile l’ovomucoide. Questo spiega perché sia necessario
in cut off più elevato per le IgE specifiche per l’ovomucoide per predire
la reattività all’uovo cotto in matrice di grano.
Kato Y, Watanabe H, Matsuda T. Ovomucoid rendered insoluble by heating
with wheat gluten but not with milk casein. Biosci Biotechnol Biochem
2000;64: 198-201
Extensively heated milk and egg as oral immunotherapy
Thermal processing can destroy IgE-binding conformational epitopes but
usually does not destroy sequential IgE-binding epitopes, and this appears
to play a role in milk and egg allergy. Food behavior under different heating
conditions, as well as interactions ith food matrix (e.g. as seen in the case of
hen’s egg white), are highly variable among different foods, and therefore,
heating may not have similar effects for all foods. In addition, thermal
processing may not simply alter IgE epitopes, as it can alter different
biophysical and immunological properties of a food protein such as its
structure, function, solubility, digestibility, and T-cell responses
[22]. Some food proteins are rendered more allergenic by thermal processing.
For peanut proteins, high temperature may enhance allergenicity
as a result of glycation (Maillard reaction) that induces the formation of Ara h 2
aggregates that are more resistant to gastric digestion and bind IgE antibody
more effectively than unheated Ara h 2
Huang F et al, Curr Opin Allergy Clin Immunol 2012; 12: 00
ICON: Food allergy
TREATMENT OPTIONS AND PREVENTION
The primary therapy for food allergy is strict avoidance of the causal food or
foods. .. Although allergen avoidance is unproved in randomized controlled
trials, it is the safest strategy for managing food allergy.
Treatment
Strict avoidance of allergens is not curative and leaves patients at risk for
accidental exposure. As such, several new therapeutic approaches are being
tested in clinical trials, but none is ready for clinical care... For a variety of food
allergens, oral immunotherapy is effective in reducing clinical reactivity in some
patients, but its ability to induce tolerance remains uncertain. In addition, the
approach places patients at risk for severe reactions and is therefore not
appropriate for widespread use. Diets containing extensively heated (baked) milk
and egg might represent an alternative approach to food oral immunotherapy;
however, further studies of this approach are necessary
Burks WA et al, JACI 2012, in press
Treatment Rather Than Avoidance May Be
Within Reach for Children With Food Allergies
“All the investigators who conduct controlled trials are
concerned because we see a lot of adverse reactions” with
the therapy, said Sampson. “If a bad accident happened because
of oral immunotherapy, it could make it pretty difficult
for us to continue research”
Slomsky A, JAMA 2012; 307: 345-6
An expanding evidence base provides food for thought to avoid
indigestion in managing difficult dilemmas in food allergy
Although there is a notion that strict avoidance speeds recovery and
delayed introduction of foods prevents allergy, various studies are
modifying our understanding of this dogma and changing how we
might present dietary information to parents. For example, recurrence
of peanut allergy has been noted when tolerated ingestion was not
continued…..
Infants are not mice, but assessment of the risks and benefits of diet
avoidance are becoming more complex and less certain. Perhaps
tolerated exposure speeds, rather than hinders, recovery from an allergy
for some children.
Sicherer SH et al, JACI 2006; 117: 1419-22
Nelson: studio
su IT SC per
arachidi
Schofield: case
report di DOPA
per uovo
Enrique: primo
RCT SLIT (con
nocciola)
1908
1905
1997
1984
Finkelstein :
case report di
DOPA per latte
Longo: RCT per
latte in bambini
anafilattici
Varshney: primo
RCT-DB per
arachidi
2005
2003
2004
Meglio: report
di casi su rivista
“autorevole”
Patriarca : report
di casi di DOPA x
alimenti
2008
2007
2011
2008
2009
Skripak: primo
RCT-DB USA
con latte
Staden: primo
RCT orale con
latte e uovo
2011
Keet: RCT
Orale vs
SLIT x latte
Hofmann: primo
studio DOPA su
arachidi
1) cosa ha contribuito a insinuare la possibilità di desensibilizzare gli
allergici alimentari? Una serie di dati, tra cui studi preliminari che ne
dimostravano l’efficacia
2) a chi va indirizzata la desensibilizzazione per alimenti? ai tolleranti
parziali o ai superallergici?
Autore
Tipo
Tipo di studio
Tipo protocollo
Alimento
Reazioni avverse
Insuccessi
1
Patriarca G, Allergol Immunopathol 1984
Orale
Aperto
Lento
Lalle\uovo\pesce
-
6,7
2
Wutrich, Monogr All 1996
Orale
Aperto
Lento
Latte
?
25
3
Patriarca G, Hepatogastroenterol 1998
Orale
Aperto
Lento
Latte\uovo\pesce\mela
71,4
15,3
4
Patriarca, Al PharmTher 2003
Orale
Aperto con controllo
Lento
Latte/uovo/pesce
67,8
16,7
5
Bauer, Abstract 2004
Orale
Aperto
Rush
Latte
100
11,1
6
Longo, Med e Bambino 2004
Orale
Aperto
Rush/lento
Latte
100
10
7
Meglio, Allergy 2004
Orale
Aperto
Lento
Latte
62
14,2
8
Enrique, JACI 2005
SLIT/sputata
RCT
Rush
Nocciola
45,4
64,6
9
De Boissieu, Allergynet 2006
SLIT
Aperto
Lento e sub massim
Latte (1 ml)
12,5
50
10
Buchanan E, JACI 2007
Orale
Aperto
Rush/lento
Uovo
100
43
11
Morisset, A Ann Clin Immunol 2007
Orale
RCT (SBPCFC)
Lento
Latte/uovo
?
11,1
12
Staden U, Allergy 2007
Orale
RCT
Lento
Latte/uovo
100
36
13
Zapatero, JACI 2008
Orale
Aperto
Lento
Latte
68,5
11,4
14
Longo, JACI 2008
Orale
RCT
Rush/lento
Latte
100
10
15
Staden, JACI 2008
Orale
Aperto
Rush
Latte (120 ml)
100
33,3
16
Skripak, JACI 2008
Orale
RCT-DB
Lento
Latte (15 ml)
35
23
17
Fernanez Rivas, Allergy 2009
SLIT/deglutita
RCT
Rush/lento e submas
Pesca (Pru P3)
100
3
18
Caminiti L, Allergy Asth Proc 2009
Orale
RCT (in parte)
Lento
Latte
80
20
19
Hofman AM, JACI 2009
Orale
Aperto
Rush/lento
Arachidi
93
7
20
Jones SM, JACI 2009
Orale
Aperto
Rush/lento
Arachidi
38
7
21
Blumchen K, JACI 2010
Orale
Aperto
Rush/lento
Arachidi
-
100/36,4
22
Pajno G , AAAI 2010
Orale
SDPCFC
A settimane
Latte
77
15
23
Kaneko H, IJACI 2010
Orale
Aperto
Lento
Latte
50
20
24
Garcia Rodriguez, JACI 2011
Orale
Aperto
Rush/lento
Uovo
78,3
13,1
25
Anagnostou K, Cl Exp All 2011
Orale
Aperto
Lento
Arachidi
86
14
26
Martorell A, Cl Exp All 2011
Orale
RCT
Lento
Latte
80
10
27
Varshney P, JACI 2011
Orale
RCT-DB
Rush/lento
Arachidi
-
16
28
Keet CA, JACI 2011
Orale/SLIT
RCT
Lento
Latte
-
-
29
Ojeda P, JMAI 2012
Orale
Aperto
Lento
Uovo
74.2
16,1
30
Garcia S, JMAI 2012
Orale
Aperto
Lento
Latte
70.5
19.1 (incl drop out)
31
Tortajada Girbes M, JIACI 2012
Orale
Aperto
Lento
Uovo
≥ 62,5
10,5





















Allen CW, Kemp AS, Campbell DE.
Dietary advice, dietary adherence and
the acquisition of tolerance in eggallergic
children: a 5-yr follow-up.
Pediatr Allergy Immunol 2009; 20:
213–8.
Kato Y, Oozawa E, Matsuda T. Decrease
in antigenic and allergenic potentials
of ovomucoid by heating in the presence
of wheat flour: dependence on
wheat variety and intermolecular
disulfide bridges. J Agric Food Chem
2001; 49:3661–5.
Urisu A, Ando H, Morita Y, et al. Allergenic activity of heated and ovomucoiddepleted
egg white. J Allergy Clin Immunol 1997; 100:171–176.
Des Roches A, Nguyen M, Paradis L, et al. Tolerance to cooked egg in an egg
allergic population. Allergy 2006; 61:900–901
Konstantinou GN, Giavi S, Kalobatsou A, et al. Consumption of heat-treated
egg by children allergic or sensitized to egg can affect the natural course of
egg allergy: hypothesis-generating observations. J Allergy Clin Immunol
2008; 122:414–415.
Boyano-Martinez T, Garcia-Ara C, azPena JM, Martin-Esteban M. Prediction
of tolerance on the basis of quantification
of egg white-specific IgE antibodies
in children with egg allergy. J Allergy
Clin Immunol 2002; 110:304–9

Inserire l’articolo di shek e savage
ITER DIAGNOSTICO DELLE ALLERGIE ALIMENTARI
ANAMNESI
DIETA DI
ELIMINAZIONE
ESAMI DI LABORATORIO
(Prick test, “RAST”, Patch test, etc.)
Diagnostica molecolare?
TEST DI SCATENAMENTO
Premessa
Estratti
Molecole
Epitopi
Premessa
Allergico al
latte
Allergico alle
molecole del latte
Nel latte vaccino vi
sono oltre 40 proteine
e tutte possono indurre
una risposta
immunologica
Allergico agli
epitopi del latte
La Beta-lattoglobulina contiene
diversi epitopi, riconosciuti dalla
gran parte dei sieri, corrispondenti
a sequenze brevi (i frammenti 4160, 102-124, 149-162) altri
riconosciuti solo dal 50-60% degli
allergici (1-8, 25-40, 92-100) altri
ancora solo dal 30-40% (78-83,
125-135) probabilmente
conformazionali.
Premessa
Estratti
Molecole
Epitopi
Maggiore complessità nella interpretazione delle risposte
1
10?
100?
Premessa
Estratti
Molecole
Epitopi
Specificità
Sensibilità
In pratica nella gran parte dei bambini
con sospetta allergia alimentare, il test
di provocazione orale (TPO) per
alimenti o test di scatenamento o, con
termine inglese, il “challenge”, è l’unico
test in grado di confermare in via
definitiva la diagnosi di allergia
alimentare.
Il TPO è tuttavia un test complicato, che
impegna sia il medico sia la famiglia, e
non è scevro da rischi per il paziente.
Sebbene sia considerato da anni il gold
standard nella diagnosi delle allergie
alimentari, presenta ancora molti punti
controversi …
Diagnosi Molecolare
ImmunoCAP ISAC
ImmunoCAP (Phadia)
Tante molecole
non significa
tutte le molecole
Circa 90 molecole disponibili
Test quantitativi
Elevata riproducibilità
Compatibilità con estratti
(procedura a due steps)
Singleplex, diagnostica mirata
Accessibilità
Volume = 50 l per molecola
112 molecole
Test semi-quantitativi
Discreta riproducibilità
Incompatibilità con estratti
Pannello rigido
Volume = 20 ml per 112 molecole
Code
Name
Latin name
f430
rAct d 8 PR-10, Kiwi
Actinidia deliciosa
f417
rApi g 1.01 PR-10, Celery
Apium graveolens
f422
rAra h 1 Peanut
Arachis hypogaea
f423
rAra h 2 Peanut
f424
f352
.. 1 nel kiwi, nel sedano,
Arachis hypogaea
nella soia e nel grano,
5 hypogaea
rAra h 3 Peanut
Arachis
nella arachide, 2 nella
rAra h 8 PR-10, Peanut
Arachis hypogaea
nocciola e 3 nella pesca).
f427
rAra h 9 LTP, Peanut
Arachis hypogaea
f354
rBer e 1 Brazil nut
Bertholletia excelsa
f428
rCor a 1 PR-10, Hazel nut
Corylus avellana
f425
rCor a 8 LTP, Hazel nut
Corylus avellana
f353
rGly m 4 PR-10, Soy
Glycine max
f419
rPru p 1 PR-10, Peach
Prunus persica
f420
rPru p 3 LTP, Peach
Prunus persica
f421
rPru p 4 Profilin, Peach
Prunus persica
f416
rTri a 19 Omega-5 Gliadin, Wheat
From Triticum aestivum
epidemiologia
clinica
diagnosi
terapia
Oral food challenges in children are safe and severe reactions
are almost all due to respiratory symptoms.
..the great majority of children
with positive challenge
developed only mild reactions.
About one third of patients
developed generalized reactions,
more frequently involving the
skin and the gastrointestinal
system, and in half of the cases
the upper respiratory tract
system. No patients had
cardiovascular symptoms.
Severe or potentially severe
reactions were all localized to
the respiratory tract: lower
respiratory (n. 6) or laryngeal
involvement (n. 5) developed in
11/254 (4.3%) OFCs.
Calvani M et al, submitted
UOVO DI GALLINA
l’ovomucoide (Gal d 1)[i]maggiormente presente nell’albume[ii], è il maggiore
allergene dell’uovo. Resiste al calore e agli enzimi acidi e proteolitici secreti
durante la digestione
l’ovalbumina (Gal d2)7 è la seconda tra le proteine allergizzanti dell’albume
anch’essa abbastanza termostabile e resistente agli agenti acidi.
l’ovotransferrina (Gal d III)7 o conalbumina, è la seconda proteina
il lisozima (Gal d IV)7 viene usato da alcune popolazioni come conservante[xi] ed
in Europa lo si aggiunge come additivo a farmaci e ad alcuni formaggi a pasta
dura per prevenire la formazione di colonie batteriche
l’ -livetina (Gal d V)7 o siero albumina del pollo, presente nel tuorlo e nella
carne del pollo, perde solo parzialmente il suo potere allergizzante se sottoposta a
cottura; è responsabile della cross-reattività tra la carne del pollo e la forfora
degli uccelli domestici
Un uovo di piccole dimensioni è costituito da
tuorlo
17 g = 29,8%
albume
33 g = 57,9%
parte non edibile
7 g = 12,3%
% Acqua
%
Proteine
% Lipidi
% Glucidi
%
Minerali
Kcal
Guscio
8,5-10,5
1
4
-
-
95
-
Albume
60-66
87-89
10,7
-
0,4-0,5
0,5-0,7
43
Tuorlo
24-30
46,5-48,5
15,8
29,1
0,15-0,25
1,1-1,6
325
Albume +
Tuorlo
90-92
74-76
12,4
8,7
0,3-0,4
0,8-1
128
% Uovo
intero
Il tuorlo è costituito dal 16% di proteine e dal 32% di lipidi
Le poteine del tuorlo sono principalmente
1) Livetina
2) Fosvitina
3) Vitellina
4) vitellinina